Know the Signs: Recognizing Different Types of Eating Disorders

Overview

Eating disorders (ED) are serious, complex illnesses that impact millions of individuals worldwide. It affects both their physical and mental health. These disorders can occur regardless of race, age, nationality, or sex. People with eating disorders develop unhealthy relationships with food, weight, and their appearance.

Eating disorders involve patterns of behaviours related to food that are unusual and unhealthy. These behaviours are not usually caused by other medical conditions. They don’t fit within what is considered normal or acceptable for a person’s development or in a cultural context. The rise in these disorders associated may be attributed to media promoting unhealthy body types, culturally endorsed body shapes, body shaming, and body dissatisfaction.

Types of eating disorders

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) by the American Psychiatric Association and the International Classification of Diseases and Related Health Problems (ICD-11) by the World Health Organization (WHO) list the following as eating disorders:

• Anorexia nervosa (AN)
• Bulimia nervosa (BN)
• Binge eating disorder (BED)
• Avoidant/restrictive food intake disorder (ARFID)
• Other specified feeding and eating disorder (OSFED)
• Pica
• Rumination disorder

Anorexia nervosa (AN)

Anorexia nervosa is defined by restriction of food intake relative to requirements even to the point of self starvation. This leads to a significantly low body weight in the individual. They have an intense fear of gaining weight and distorted body image which prevents them from recognizing the seriousness of their condition. The disorder usually occurs in late adolescence and early adulthood. It is more prevalent in women than men.¹

They extremely fear becoming fat, deny feeling hungry and compulsively exercise for extended periods of time. They exhibit food restrictive behaviours (calorie counting or portion control) and purging methods (self-induced vomiting or use of diuretics, laxatives). A combination of genetic, biological, behavioural, psychological, and social factors increase the risk of anorexia nervosa.¹

The symptoms of anorexia nervosa are:^1,2

Anorexia nervosa leads to many complications and long term effects on the body including anaemia, heart problems, low blood pressure, brain damage, kidney problems, obstetric complications in women, low testosterone in men, bone loss, multi-organ failure and even death.

Bulimia nervosa (BN)

This disorder comprises episodes of binge eating followed by inappropriate compensatory behaviours to prevent weight gain. During the bingeing episode, patients eat more significant portions of food than most people in a similar period (usually less than 2 hours). The patient cannot control bingeing and reduce the servings they consume. After the bingeing episode, they induce vomiting (often secretly), use laxatives, exercise extremely and refrain from eating to prevent weight gain.^3,4

These alternate episodes should occur at least once a week for about three months to confirm the diagnosis of bulimia nervosa. People with eating disorders share certain traits such as low self-esteem, fear of getting fat, intense unhappiness with their body appearance, feelings of helplessness. In stressful and anxious situations, they tend to binge eat, but this is followed by feelings of guilt and disgust. Purging provides them with short-term relief.⁴

The symptoms of bulimia nervosa are:⁴

• Normal or above average body weight
• Irregularities in menstrual periods
• Inflamed or sore throat
• Dental (enamel) erosion from vomiting
• Dehydration
• Hypotension
• Dry skin
• Parotid gland swelling
• Calluses on the dorsal aspect of the hand (Russel’s sign)
• Hair loss
• Edema
• Epistaxis
• Tiredness

The complications of bulimia nervosa are stomach rupture, inflamed oesophagus, metabolic alkalosis, heart problems, kidney problems, substance abuse and other mental health problems and suicidal behaviour.

Binge eating disorder (BED)

Binge eating occurs when a person consumes a large amount of food in a short period (over a two hour period) and feels unable to control what or how much they are eating.⁵ Regularly binge eating at least once a week for a period of 3 months may indicate the presence of binge eating disorder. Occasionally, everyone overeats especially during holidays or special events. But constantly feeling out of control while eating large amounts of food may indicate binge-eating disorder.

Individuals with this disorder have behaviours like eating when not hungry or already full, rapidly consuming large amounts of food during binges, eating until feeling uncomfortably full, and frequently eating alone or in secret. Those with the disorder often feel embarrassed or ashamed about their binges. They may try to restrict their eating, which can worsen the cycle of binge eating. People with bulimia nervosa regularly try different methods to prevent weight gain after binge eating, whereas those with binge eating disorder might occasionally try these but not regularly.

Most individuals with binge eating disorder experience distress about their body size or shape, regardless of their actual weight. This disorder is linked to numerous issues, including weight gain, type 1 and type 2 diabetes, heart disease, depression, anxiety, suicidal thoughts, sleep disorders, digestive system problems, joint and muscle pain, and impaired social functioning.⁵

Avoidant/restrictive food intake disorder (ARFID)

Avoidant/restrictive food intake disorder (ARFID) is a disturbance in eating or feeding patterns without the fear of weight gain, drive for thinness, or body dysmorphia that are typical in other eating disorders.⁶ Individuals with this disorder limit the amount and type of food they consume. This can lead to decreased variety and volume of food intake, which can result in a persistent failure to meet appropriate energy, nutritional needs and psychosocial impairment.

It can affect individuals of all ages, though it is most common in childhood. Risk factors include⁶

• Traumatic experiences related to food (e.g., food insecurity, force-feeding, choking)
• Underlying conditions affecting neurological function or development [e.g., anxiety, depression, Attention Deficit Hyperactivity Disorder (ADHD)]
• Aversions to certain food textures
• Fears of food harming the body
• Family history of eating disorders

It can begin in early infancy or childhood and may persist into adulthood. Unlike picky eating, which targets a few foods and doesn’t affect a child’s appetite, growth, or development, this disorder can lead to serious nutritional deficiencies and doesn’t resolve without treatment. Patients are more likely to be male, in the age group of 4–11 years. They have a longer duration of illness compared to those with other eating disorders. It can affect socialisation since patients try to avoid social situations involving food.

The complications of avoidant/restrictive food intake disorder are as follows⁶

• Severe malnutrition
• Dehydration and electrolyte imbalance
• Anaemia
• Low blood pressure
• Osteoporosis
• Cardiac arrest
• Delayed puberty
• Changes in physical growth
• Significant weight loss requiring hospitalisation due to medical instabilities

Pica

Pica is defined as eating non-nutritive, non-food substances over a period of at least one month.⁷ This disorder involves the consumption of non-food items like soil, raw starches, ice, charcoal, ash, paper, chalk, cloth, baby powder, coffee grounds, eggshells, faeces of any kind, hair, thread, paint chips, pebbles, pet food, soap, wool

etc. Pica is seen in children and also common in intellectually impaired patients. Pica is observed in women during pregnancy. While it usually manifests as an isolated disorder, there are occasions where it coincides with conditions like schizophrenia, Obsessive Compulsive Disorder (OCD), and trichotillomania (compulsively pulling out one’s own hair).⁷

Pica can cause other conditions such as⁸

• Anaemia
• Ascariasis (roundworm infection)
• Constipation
• Small intestine and large intestine obstruction/blockage
• Electrolyte imbalance
• Arrhythmias (abnormal heart rate or rhythm)
• Lead poisoning

Pica can be diagnosed only if the individual is at least 2 years old. Healthcare providers may overlook the condition for several reasons. Patients may not disclose their symptoms or those concerning their children. Since infants and young children naturally explore objects orally and put things in their mouth, it is challenging to distinguish between this normal developmental behaviour and the signs of pica.⁸

Rumination disorder

Rumination syndrome is a functional gastrointestinal disorder defined as the effortless regurgitation of recently ingested food from the stomach back into the oral cavity in the absence of organic disease.⁹ It occurs within 15 minutes after eating and lasts up to two hours. This condition affects individuals of all ages and significantly impacts their quality of life. Symptoms of rumination syndrome are usually chronic, and it may take an average of 21 to 77 months to receive a diagnosis.

Several risk factors have been identified, including⁹

• Emotional neglect in infants
• Emotional stress
• Mental health diagnoses such as Obsessive Compulsive Disorder (OCD), anxiety, depression, Attention Deficit Hyperactivity Disorder (ADHD)
• Developmental delay
• Fibromyalgia
• Rectal evacuation disorder

Patients with rumination syndrome often report symptoms such as dyspepsia, vomiting, and abdominal pain. Some patients experience an urge or impending abdominal pain before regurgitation occurs. Frequent episodes of regurgitation can lead to significant weight loss and dehydration. Rumination syndrome is regarded as an acquired habit, making it a reversible condition.

Other specified feeding and eating disorder (OSFED)

Other specified feeding and eating disorders include feeding disorders and eating disorders of clinical severity that do not meet diagnostic criteria.¹⁰ They are as follows:

1. Atypical anorexia nervosa: Meets the criteria of anorexia nervosa but the individual’s weight remains within or above the normal range, despite significant weight loss
2. Atypical bulimia nervosa: Fulfils the criteria for bulimia nervosa but with episodes that occur less frequently.
3. Binge-eating disorder of low frequency and/or limited duration: Meets the criteria of binge eating disorder, but with less often episodes
4. Purging disorder: Purging without binge eating
5. Night eating syndrome: Recurrent night time eating after awakening from sleep or excess calorie intake after the evening meal

Treatment for eating disorders

Treatment for eating disorders involves a comprehensive approach including psychological therapy, nutrition education, medical monitoring, and sometimes medications. Addressing health problems caused by eating disorders is crucial. Treatment plans are adjusted according to each person’s specific requirements. A specialised treatment team including mental health professionals, dietitians, dental and medical specialists is the first step. Family involvement is important, especially for young individuals.¹¹

1. Psychotherapy helps to normalise eating patterns, address distorted thoughts and develop coping skills. Various types of therapy, such as cognitive behavioural therapy and family-based therapy, may be used.
   
   
2. Registered dietitians provide education on nutrition, meal planning and healthy eating habits. Goals include achieving a healthy weight and understanding the impact of nutrition on overall health.
   
   
3. Medications alone cannot cure an eating disorder. They may be recommended alongside psychological therapy to help manage symptoms, such as alleviating depression or anxiety.
   
   
4. In severe cases or when other treatments fail, hospitalisation may be necessary to stabilise acute medical symptoms. The process of restoring eating habits and achieving a healthy weight mostly begins in outpatient care.
   
   
5. For individuals requiring long-term care or those with persistent health issues despite hospitalisation, residential treatment is recommended. It involves temporary residence at an eating disorder treatment facility
   
   
6. Serious health issues like systemic problems, electrolyte imbalances, and nutrient deficiencies, can arise from eating disorders, requiring ongoing monitoring and treatment.
   
   
7. Active participation in treatment is essential for successful recovery. Patients and their families should seek reliable information and support from the treatment team and reputable sources to avoid misinformation.¹¹

References:

1. Moore, Christine A., and Brooke R. Bokor. “Anorexia Nervosa.” StatPearls, StatPearls Publishing, 2024. PubMed, http://www.ncbi.nlm.nih.gov/books/NBK459148/.
2. Anorexia Nervosa. 13 May 2024, https://www.hopkinsmedicine.org/health/conditions-and-diseases/eating-disorders/anorexia-nervosa.
3. Bulimia Nervosa. 26 Apr. 2024, https://www.hopkinsmedicine.org/health/conditions-and-diseases/eating-disorders/bulimia-nervosa.
4. Jain, Ashish, and Musa Yilanli. “Bulimia Nervosa.” StatPearls, StatPearls Publishing, 2024. PubMed, http://www.ncbi.nlm.nih.gov/books/NBK562178/.
5. “Definition & Facts for Binge Eating Disorder – NIDDK.” National Institute of Diabetes and Digestive and Kidney Diseases, https://www.niddk.nih.gov/health-information/weight-management/binge-eating-disorder/definition-facts. Accessed 6 June 2024.
6. “What Is ARFID (Avoidant/Restrictive Food Intake Disorder)?” Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/24869-arfid-avoidant-restrictive-food-intake-disorder. Accessed 14 June 2024.
7. Al Nasser, Yasser, et al. “Pica.” StatPearls, StatPearls Publishing, 2024. PubMed, http://www.ncbi.nlm.nih.gov/books/NBK532242/.
8. “Pica: What It Is, Causes, Symptoms & Treatment.” Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/22944-pica. Accessed 6 June 2024.
9. Kusnik, Alexander, and Sarosh Vaqar. “Rumination Disorder.” StatPearls, StatPearls Publishing, 2024. PubMed, http://www.ncbi.nlm.nih.gov/books/NBK576404/.
10. Krug, Isabel, et al. “Editorial: What Do We Know About Other Specified Feeding or Eating Disorders, Unspecified Feeding and Eating Disorder and the Other EXIAs (e.g., Orthorexia, Bigorexia, Drunkorexia, Pregorexia Etc.)?” Frontiers in Psychology, vol. 13, July 2022, p. 953402. PubMed Central, https://doi.org/10.3389/fpsyg.2022.953402.
11. “Eating Disorder Treatment: Know Your Options.” Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/eating-disorders/in-depth/eating-disorder-treatment/art-20046234.Accessed 14 June 2024.

Disclaimer: The information provided is for general informational purposes only and is not intended to replace professional medical advice. Always seek the guidance of your doctor or other qualified health professionals with any questions you may have regarding your health or a medical condition.